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Download Fillable Form Cms-1763 In Pdf - The Latest Version Applicable For 2024. Fill Out The Request For Termination Of Premium Part A, Part B, Or Part B Immunosuppressive Drug Coverage Online And Print It Out For Free.
Use this form: • If you have premium Part A or Part B, but wish to no longer be enrolled. • If you have Part B, but recently re-joined the workforce with access to employer-sponsored health insurance and wish to voluntarily terminate this coverage.
The CMS-1763 is used by beneficiaries to request voluntary termination from Premium Hospital (premium-HI) and/or Supplementary Medical Insurance (SMI). The latest form for Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (CMS-1763) expires 2021-05-31 and can be found here.
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You must submit Form CMS-1763 (PDF, Download docHub Reader) to the Social Security Administration (SSA). Visit or call the SSA (1-800-772-1213) to get this form.
The completion of this form is needed to document your voluntary request for termination of Medicare coverage as permitted under the Code of Federal Regulations. Section 1838(b) and
